Name of Child

Age and date of Birth

Parents / Carer’s name(s)

Home Address

Ethnicity

A White

□ British                                          □ Irish

□Any other white background (please specify):

B Mixed

□ White & Black Caribbean              □ White & Black African

□ White & Asian

□Any other mixed background (please specify):

C Asian or Asian British

□ Indian                             □ Pakistani                          □ Bangladeshi

□Any other Asian background (please specify):

D Black or Black British

□ Caribbean                                     □ African

□Any other Black background (please specify):

E Chinese or other ethnic group

□ chinese

□Any other background (please specify):

Your Name

Your Position

Date and Time of incident

Are you reporting your own concerns or responding to the concerns raised by someone else?

Yes                □                               No                 □

If so, please provide their name and position within the Club

Please provide details of the incident / or concerns you have, including dates, times, venue etc

Please detail exactly what was said if your concerns are as a result of a child speaking to you, including date, time and venue

Have you spoken to the parents?

Yes          □          No           □

If yes, please provide details of what was said

Have you spoken to the child?

Yes          □          No           □

If yes, please provide details of what was said

Have you spoken to the person the allegations are being made against?

Yes          □          No           □

If yes, please provide details of what was said

Please provide details of further action taken to date

Have you informed the statutory authorities?

Social Services          Yes          □          No          □

Police                         Yes          □          No          □

Please provide the name of the person and their contact number

Name of any person accused

Date of Birth

Address

Your signature

Date

Time